Contract Pharmacy Details

DANA'S PHARMACY
CAH451345-01 Crosbyton Clinic Hospital

Covered Entity Details

Entity Name

Crosbyton Clinic Hospital

Subdivision Name

Crosbyton Clinic Hospital Rural Health Clinic

Type

Critical Access Hospital

340B ID

CAH451345-01

Entity Address

710 West Main Street
Crosbyton, TX 79322

Medicare Provider Number

451345

Outpatient Facility Provider Number

458829

Participating Start Date

1/1/2012

Last Recertification Date

8/19/2019

Entity Termination Date

10/1/2020

Pharmacy Details

Pharmacy Name

DANA'S PHARMACY

Pharmacy Address

315 BURLINGTON AVE
SPUR, TX 79370-2812

Pharmacy Comments

Contract Details

Approval Date

10/3/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Debra Miller, Administrator
(806) 675-8700

Contract Pharmacy Representative

Dana Tilton, Owner
(806) 271-3394

Signed By Date

10/3/2013